Rosen's Breast Pathology, 4e

895

Unusual Clinical Presentation of Carcinoma

A

B

FIG. 33.1.  Breast carcinoma in pregnancy. A: Metastatic breast carcinoma in the placenta. Clus- ters of metastatic carcinoma cells ( arrows ) are present in the intervillous spaces. B: The patient had a poorly differentiated invasive ductal breast carcinoma ( upper right ), late in the second trimester of pregnancy, with a partial pathologic response to chemotherapy.

from a statewide tumor registry for patients treated between 1985 and 1992 suggest that age-related differences in prog­ nosis are influenced by the stage at diagnosis. 54 Patients Younger Than 40 Years Simmons et al. 55 investigated the incidence of breast carci­ noma in women younger than 25 years of age by review­ ing data from a Minnesota county between 1935 and 2005 for histologically confirmed cases. The four cases diagnosed over the 1,201,539 person-years yielded an annual age-­ adjusted incidence of 3.2 per million (95% CI, 0.1 to 6.2). Since all patients were in the 20- to 24-year age group, the age-specific incidence in this subset was 16.2 per million. The authors noted that delay in diagnosis was a common feature in these cases. Kothari et al. 56 reported on 15 women 25 years or younger at the time of diagnosis. Two patients had intraductal carci­ noma. None of the invasive carcinomas in 13 patients were low grade. Nine (69%) of the 13 women with invasive carci­ noma died as a result of recurrent carcinoma—with a me­ dian DFS of 86 months. There was no statistically significant difference in overall survival (OS) between women 25 years or younger and those 26 to 35 years of age at the time of diagnosis. Feldman and Welch 57 studied 29 women who were younger than 30 years when diagnosed and treated for breast carcinoma. The patients were identified between 1953 and 1983 in the records of an urban teaching hospital. Age at diagnosis ranged from 20 to 29 years. Seven patients (26%) were pregnant at the time of diagnosis. Delay in diagnosis was probably a factor in the prognosis of these patients since the stage at diagnosis was II or higher in 26 of 27 cases with documented data. Twenty-two patients (76%) died of breast carcinoma, including three who developed recurrences 12.7,

14.6, and 19.9 years after diagnosis. It should be noted that virtually all patients were treated by mastectomy and none received systemic adjuvant therapy. A larger series of patients 30 years or younger at diagno­ sis, consisting of 185 women, was reported by Xiong et al. 58 The distribution of patients by stage was as follows: stage I, 11%; stage II, 45%; stage III, 38%; and stage IV, 6%. Treat­ ment consisted of various combinations of mastectomy or breast-conserving surgery with adjuvant or neoadjuvant chemotherapy and radiotherapy. The 5-year OS rates by stage were stage I, 87%; stage II, 60%; stage III, 42%; and stage IV, 16%. When compared with control patients identi­ fied in the National Cancer Data Base, women diagnosed at age 30 or younger had poorer 5-year OS rates. A retrospective case-controlled study by Peng et al. 59 concluded that diagnosis at or before 35 years of age was an independent negative prognostic risk factor. They com­ pared 551 women 35 years or younger who had operable breast carcinoma to a cohort of women 36 to 50 years of age at diagnosis matched for year of diagnosis, family history, pathologic stage at diagnosis, hormone receptor status and adjuvant therapy. The younger women had a significantly shorter disease-free interval to first recurrence (median 23.2 vs. 28.4 months), a lower DFS (63.7% vs. 74.7%), and lesser OS (79.5% vs. 85.6%). Liukkonen et al. 60 studied 212 Finnish women treated between 1997 and 2007 for breast carcinoma who were younger than 35 years. At diagnosis, 117 (55%) had axil­ lary nodal metastases and 14 (7%) had distant metastases. One hundred and forty (65%) women were treated with mastectomy and 68 with breast conservation surgery. Post­ operative treatment included chemotherapy, endocrine therapy, and ­radiation, singly or in combination. Local ­recurrence ­occurred in 10 (15%) of women treated with breast conservation surgery, and 8 (6%) of patients treated